Who Is Being Referred?Name(Required) First Last Preferred Name (if relevant)Address Street Address Address Line 2 City Post code GenderNHS number (if known)Email for person being referred Is the person being referred happy to be contacted via email Yes No Do not know Phone number (only If aged 16 and over)Is the person being referred under the age of 19?(Required) Yes No If under the age of 19, we will need the contact details and address of the parent or guardian. If assessment is offered we expect a parent or carer to attend for those aged 16 and under. For those aged 17 and 18 we like to offer family assessments, if this is possible please do provide contact details.Name of parent or guardian First Last Is your address the same as the person being referred?????? Yes No Address of parent or guardian Street Address Address Line 2 City Post code Phone number for parent or guardianWho is making the referral?Is this a self referral? Yes No What is your relationship with the person being referred? Parent Guardian Other Family Member (Please state) Professional (Please State) Friend Other (please state) Please describe your relationship with the person being referredIs your address the same as the person being referred? Yes No Address Street Address Address Line 2 City Post code Referrer phone numberReferrer email(Required) Has the person being referred (or a parent if they are below age 16) consented to this referral? Yes No Please explain why you have selected no.Alternatively, you can call us at Brownhills on 0300 421 3887 to discuss consent before completing the referral. Please be aware we will not accept a referral without consent unless a clear reason is provided or you have spoken to us first.GP DetailsGP Name First Last GP surgery address Street Address Address Line 2 City Postal code Information Which Helps Us to Understand Your Eating DifficultiesCurrent height – please enter in cmCurrent weight – please enter in kgWhere and when was weight last recorded? Please state if estimatedIf you have been unable to provide this information, please explain why?Weight pattern over recent monthsHas weight gone up or down? If you do not know the specific weights, have clothes sizes changed? If for a young person have their weight and height been going up as expected?Reason for referral, including estimated age eating difficulties startedDo you believe that the eating difficulty is related to any of the following? A strong desire to change your body, either by losing weight or gaining muscle A lack of interest in food A fear of vomiting or choking on food The sensory characteristics of food (e.g. do you struggle with certain tastes or textures) Other Please explain these eating difficulties furtherAre there any additional concerns?Please elaborate and note any help currently being provided (e.g. by a counsellor or by the GP) General Mental Health Problems with Relationships Problems with School or Work Significant recent life events which it would help for us to know about Physical Health Concerns Neurodivergence (including traits and/ or diagnoses of autism and ADHD) Alcohol or substance misuse Other Please explain these additional concerns and add teams they may be working with or interventions they may be havingHave the difficulties been discussed with any other professionals, and if so what is their involvement?Please consider school, health visitor, GP, dietician, social workers and CAMHS. Current Food IntakePlease go into detail, what specifically is had, the quantities, and the timings of meals, if possible please give an example of a typical days eating.Current Fluid IntakePlease provide details of types of fluid and approximate amount (e.g. number of cups/glasses/cans/bottles)Do you experience periods of binge eating?E.g. eating more than planned, in an uncontrolled manner? Yes No If yes, please provide more detail, including frequencyDo you experience periods of self-induced vomiting? Yes No If yes, please provide more detail, including frequencyDo you take laxatives, diuretics, anabolic steroids, weight loss injections and/ or diet pills? Yes No If yes, please provide more detail, including frequency and where the medications are purchasedFor example, are they prescribed by the GP, purchased from a chemist, or purchased online?Do you exercise excessivelyFor example, exercising even when you are too tired, in a way that is no longer enjoyable? Yes No Please provide more detail, including frequencyAre you currently a member of any weight loss groups or services? Yes No If yes, please provide more detailAre you currently pregnant, or have you given birth in the last year? Yes No Do you have diabetes? Yes - type 1 Yes - type 2 No How is your diabetes managed and is it currently stable?Have you had any bariatric / weight loss surgery? Yes No Please describe the surgery you have hadHave you had any previous support for an eating disorder? Yes No What type of support have you had?Are there any difficulties which you will have in accessing our service which you think we need to know about?Is there anything else you think we should know?CAPTCHA